patient records fit for modern health care

Promoting Excellence in Family Medicine

Patient records fit for modern health care

Professor Mayur Lakhani FRCGPChairman of UK Council

CONFERENCE ON THE DATA ACCREDITATION STANDARD FOR THE IM&T DES, Leicester 4th July 2006

Promoting Excellence in

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About the RCGP

Set standards for the quality of care provided by GPs Provided by teams in a practice – practice quality awards

Education and training of GPs The MRCGP Examination

Voice of general practice when it comes to quality and standards Involvement of patients in decision making and assessmentsStrong health informatics function


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Celebrate the Quality of Electronic Patient Records in Primary Care

Recognise the achievement of the QOF and the part that ICT played in this (Practice systems and QMAS)Great strides have been made in developing the electronic record in family medicine in the UKCelebrate this! – we have come a long way


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Hellebek, Ejdrup

What causes medical errors?


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The headlines!


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IM&T DES Welcome it! good news for patients

It is about Better Patient Care >Quality and Safety of Health CareThrough education, training and support of Primary Care Health Team Supporting local health economies Good records are an integral part of healthcare - they are not an add on it is not about the technology!


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My presentation

Patient records fit for modern health careThe case for high quality electronic patient records in the context of modern health care – what is it like to a patient and a health care professional? The case for standard setting and accreditation Take home messages – both for clinicians and the PCTs teams


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Modern Health Care


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Modern Health Care

Practices do not work in isolation – part of a complex network of health care providers and virtual teams


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Interfaces in Health Care

GP practice

Nurse triage

Out of Hours Co-op

Walk in centres

A and E

NHS Direct

Alternative primary care providers

GPwSI

PwSI

Intermediate Care

Hospital Care


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Fragmentation

multiple points of access, and increased number of interfacesIncreased number of services and health care professionals involvementTechnical complexity is increasing, both in general practice and in the NHS as a wholeCo-morbidityWithout (usually) a shared health record = loss of information


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Values

Patients do not like repeating storiesPatients do suffer disruption of care across interfacesValue continuity and interpersonal care Value attempts to coordinate careIntegration and co-ordination of care is a crucial requirement in a health service Fragmentation of Care – ‘hand offs’ Continuity is a relevant concept both in both primary and secondary care


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The importance of continuity

1. Informational continuity - the use of information on past events and personal circumstances to make current care appropriate for each individual.2. Management continuity – a consistent and coherent approach to the management of a health condition that is responsive to a patient’s changing needs.3. Relational continuity – an ongoing therapeutic relationship between a patient and one or more providers (Haggerty et al, 2003)


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Delayed diagnosis of cellulitis, complications & penicillin allergy

A lady of 48 with an undiagnosed severe mental health problem missed an appointment at the GP practice. 2 appointments missed in one day [access, mental health problem]. She attended a W.I.C. one week later and a diagnosis was made of cellulitis and a prescription for flucloxacillin was made under a PGD.The next day a florid rash developed – the patient was known to be allergic to penicillin but did not state it at the time [allergy well-documented in GP records but not at WIC]


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Delayed diagnosis of cellulitis, complications & penicillin allergy

Own GP changed abs to erythromycin but patient could not afford prescription and re-presented at the W.I.C but she did not wait to be seen.

Subsequently patient was briefly admitted to hospital with cellulitis and fever (no letter received].

GP contacted W.I.C. to give background information and summary as likely to be frequent presenter at W.I.C. Information about allergy shared


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Results out of hours and delay in managing complications

High INR (>10)

Abnormal FBC (myeloproliferation)

High potassium level

Anaemia

Methotrexate level

Systems to deal with results OOH: Communication arrangements


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Scenario

A 42 y.o. man presented with a history of feeling generally unwell, anorexia and vague abdominal discomfort. Clinical evaluation did not give any clues and a set of initial blood investigations were negative. The patient presented again 2 months having lost some weight. Again there were no localising features but the GP was concerned about an occult malignancy. His sixth sense suggested something seriously wrong. An urgent referral was made to the hospital. More than 12 months later the patient presented with an unrelated problem [ankle injury]. The GP inquired about the above appointment – the patient stated that he never received the appointment. Anyway he had felt better and did not ‘need it now’ What issues does this raise?


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Good electronic patient records in primary care are essential for:

good clinical decision making and to continue the care of a patient for medico-legal protectionTo meet contractual and payment mechanisms (QOF) To allows teams to deliver care To co-ordinate and integrate care across the patient journey Follow up, audit and research, teaching and training Understanding the health needs of the population Supporting Commissioning


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Wanless Report (2002)

National, integrated ICT systems across the health service can lay the basis for the delivery of significant quality improvements and cost savings over the next 20 years. Without a major advance in the effective use of ICT (and this is a clear risk given the scale of such an undertaking), the health service will find it increasingly difficult to deliver the efficient, high quality service which the public will demand. This is a major priority which will have a crucial impact on the health service over future years.


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The case for standards and accreditation


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The crunch questions

How good are electronic patient records in primary care?

How can we make them even better?

How would we make this judgement?

How can we support improvement?


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Some current problems with electronic patient records

Inaccuracy of summaries – patient safety issues e.g. MIProblem list management (the summary list containing ‘ear wax’ or URTI)Variation in morbidity recording - distinctiveness of diagnosis and inconsistent codesNot all relevant data being captured ‘Reams of stuff’ when patient sent into hospital The problem of dual records! (manual and electronic)


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In the NHS

Almost one million people visit their GP every working day

Almost 90% of problems are dealt with in general practice

About 350 million consultations with general practitioners per year

78% of people consult their general practitioner at least once during the year


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Studies from Keele University

Quality of recording varies between morbidities High quality coding can be achievedA program of assessments, feedback, and training appears to improve data quality in a range of practices. Needs a trained support team to implement


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Standards for electronic health records

Education and training issues – what training do doctors get in this area and what is performance like?

Clear need for standards and accreditation

Working with patients and users

Clinical engagement is crucial


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Acting on Letters

A practice received a letter from an optometrist recommending referral of patient with raised IOPThe GP expected the patient to attendNo referral was madeDelayed referral for GlaucomaNeed good systems for dealing with correspondence and capturing important events/action on the electronic patient record


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Skill mix and different ways of working – recording all contacts


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Coding of data: Has the patient had an ovary removed?

Omentectomy versus oophorectomy

‘I can only presume that the midwife who entered the details onto the computer has read omentectomy from the operation note and has erroneously entered this as oophorectomy.


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Abbreviations - A Case of Mistaken Identity Extract from a letter

Mr ….was by mistake given an appointment for my outpatient clinic today. This resulted from the similarities between Dr M… initials and mine. Dr M. initials are JFM and mine are JKM. …

Urology versus Gastroenterology!


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Take home messages


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Message for clinicians

Leadership and commitment

Shared responsibility

ICT can support clinicians improve the quality and safety of care

professional development, commissioning - need for measurement


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Doctor’s Portfolio

Criteria/standards/evidence

AppraisalHow am I doing?

Clinical GovernanceLocal Certification

How is the doctor doing?

Assessment: Local Panel Evaluation of Portfolio including lay members: Can the doctor be recommended

for revalidation?

Revalidation

Good record

keeping –

essentia

l part

of

being a d

octor


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Message for the conference

Good quality electronic medical records are an essential part of a modern professional life and health care system(s)Welcome the IM&T DES - peer review of systems (accreditation) is a notable way of driving up standards Leadership and commitment from doctors and nurses is essential as is working with patients and users We need to raise our game in completeness and accuracy of coding Training, education and support is crucial from PCTs

patient records fit for modern health care

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